Cardio Oncology - Dr. Rakesh Gopal

06/03/2025

03/03/2025

26 year old with testicular tumor . Has secondaries. This time admitted for chemotherapy with Paclitaxel Gemcitabine and carboplatin. Patient had acute ST elevation anterior wall MI . He was thrombolysed with tenectaplase and standard of care for ACS . Primary angioplasty was not considered as we find either normal coronaries or a thrombus filled artery in such cases especially those who have no coronary risk factors or prior events or symptoms . Day 3 , his clexane and aspirin was stopped and Eliquis and Plavix was continued. A CT angiogram done at three weeks showed normal coronaries. No evidence of atherosclerosis. Acute cardiac events during cancer therapy is a different ball game

22/02/2025

Timely updates info on advanced technology and scientific progress in China. Run by , t

21/02/2025

LV Dysfunction and Trastuzumab therapy .

65 years old .
Carcinoma left breast post MRM , chemotherapy with Paclitaxel and Trastuzumab. Diabetic Dyslipidemic and Hypertension with hypertensive heart disease. Possible co existing Hypertrophic cardiomyopathy with no LVOT obstruction. morphological mitral stenosis mild mitral regurgitation. May 2024 . Presented with severe LV dysfunction but no heart failure in December 2024 . Her Trastuzumab was with held else where . Heart failure therapy was not according to GDMT . What next ? Permanently discontinue Trastuzumab that can cure cancer ? We treated her with rapidly up titrated maximal doses of GDMT . LV function normalised in January 2025 . As Trastuzumab induced LV dysfunction is reversible because it is secondary to myocardial energy kinetics and it cures cancer it was decided to restart Trastuzumab . Echo done 20/2/ 2025 showed deterioration of LV function . No symptomatic heart failure. Good response to cancer treatment. She was started on Digoxin . Decided to continue Trastuzumab after discussing the case in detail about the reversibility of LV dysfunction and advantage of continued cancer therapy . A dobutamine contractile reserve study can help in such cases . We don’t believe in denying life saving cancer therapy when cardiac dysfunction is eminently treatable and patient can be kept alive…

20/02/2025

Immune myocarditis
72 year old man with non small cell lung cancer status post NACT premetrqx and carboplatin 2/12/24 . Immunotherapy since 28/1/25 . Presented with severe back pain. MRI showed L1 wedge compression fracture , skeletal mets and PET showed progressive disease . Extreme fatigue and rapidly progressive breathlessness. Tachycardia and tachypnea . ECG showed nonspecific T wave changes . Troponin I negative. NT proBNP 3800 . CRP elevated . ESR 14 mm at end of one hour . Good LV systolic function. LV diastolic dysfunction. Mild MR . No RWMA . No PAH . Strain rate imaging showed patchy loss of strain not congruent to any arterial territory. Bilateral pleural effusion, drained 700 mL from right side under ultrasound guidance .
Treated with diuretics, Bisoprolol, Ivabradine , Dapaglifozin and Methyl Prednisolone 1000 mg IV OD
Near complete resolution of symptoms in 24 hours .
There is no single diagnostic test that alone can make a diagnosis of immune myocarditis. Difficult with MRI in a sick patient. Since patchy involvement biopsy may not always help . Biomarkers have less sensitivity. But if we combine clinical features , ECG , Troponin , NT proBNP CRP and strain rate imaging we can make a life saving diagnosis in majority of the cases.
what starts as a mild symptomatic case can progress very quickly and if patient develops severe heart failure, ventricular arrhythmia or complete heart block , unless they receive at least 850 mg of IV methyl prednisolone , mortality can be very high.

19/02/2025

Paclitaxel Gemcitabine induced cardiac injury

21 year old had mixed germ cell tumor, orchidectomy and chemotherapy in September 2023 . Had lung nodule . Developed paraplegia requiring D 9 to D 11 laminectomy with excision of lesion 22/1/2024 . Admitted this time for chemotherapy. Paclitaxel , Gemcitabine and carboplatin . Patient had typical retrosternal pain 30 minutes past chemo . Compared to previous ECG new onset ECG changes , ST coving, T wave inversions . Had standard of care for ACS . No primary angioplasty attempted since we see only normal coronary or thrombus filled artery in cancer patients post chemotherapy especially when there are no coronary risk factors. His troponin I is negative. Planned for cath Angio in case symptoms recur other wise CT angiogram prior to discharge. This has been our policy . Paclitaxel and Gemcitabine can cause myocardial infarction though rare . Please see the ECG in video , Pre chemotherapy , during pain and after complete ST resolution.

17/02/2025

Ruby … don’t take every MI to cath lab . 5FU . 52 year old had acute infero lateral wall MI while 5FU on flow . No prior cardiac events symptoms or risk factors . Thrombolysed and Tenectaplase within 5 minutes of pain and ECG . Complete ST resolution no Q waves at 90 minutes . Good LV function . RWMA present . Standard Medicare . LMWH and aspirin discontinued after three days . Plavix and Eliquis was started . No further events . Optimal CT angiogram after four weeks. No trace of atherosclerosis. No plan to further 5FU .

24/01/2025

Cardiovascular disease is more common in cancer patients

65 year old with carcinoma esophagus post RT and chemo with Paclitaxel and Carboplatin in October 2024 . Hypertensive with renal impairment. Had chest pain typical of angina and ECG showed acute anterior wall MI with RBBB one week after last Chemotherapy in November 2024 . His CAG showed tight proximal LCx disease with type II LAD . LCx was directly stented . Uneventful recovery . RBBB resolved . Follow up in Jan 2025 showed Good LV function, LVH GLS - 21.5 %. NSR . NYHA class I .
It is difficult to ascertain if MI was related to cancer therapy , however cancer patients are more prone for acute MI than normal population. Most of the time , since cancer many don’t get proper treatment for myocardial infarction . That is not appropriate . An MI in a cancer patient should be treated as aggressively as in a patient with no cancer . This patient has good result post PCI and his cancer is stable .
Cancer patients should not be left out without treatment for any condition that may arise .